We're unable to sign you in at this time. Please try again in a few minutes.
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Special Feature |

Pathological Case of the Month FREE

Juan C. Sanchez, MD; Janine E. Sanchez, MD
[+] Author Affiliations

Section Editor: Enid Gilbert-barness, MD

Arch Pediatr Adolesc Med. 1998;152(8):827-828. doi:10.1001/archpedi.152.8.827.
Text Size: A A A
Published online

A 15-YEAR-OLD black girl presented with complaints of intermittent vomiting, abdominal pain, and vaginal bleeding during the past month. She gave a history of having been raped 2 months earlier.

On pelvic examination, the uterine size was consistent with a 12-week pregnancy. Her last menstrual period had occurred 10 weeks earlier. Medical history was noteworthy only for easily controlled asthma. She was taking no medications. The urine pregnancy test results were positive. β-Human chorionic gonadotropin (hCG) concentration in blood was 673160 IU/L (normal for this stage, <200000 IU/L). Abdominal ultrasound showed a 10.6×7.0×10.0-cm heterogeneous mass involving the uterus and containing cystic areas.

Suction dilatation and curettage were done. A brownish-tan, irregularly shaped, membranous, spongy mass with multiple translucent, membranous cysts was removed (Figure 1 and Figure 2). During the procedure, the patient had a narrow complex tachycardia with a heart rate in the 180 range (prior to surgery, 95). The ECG revealed sinus tachycardia (130-150 /min) with a short PR interval and a delta wave consistent with a diagnosis of Wolff-Parkinson-White syndrome (WPW).

Because of the sinus tachycardia, hematocrit and thyroid function tests were ordered. The hematocrit had decreased to 0.18, from a level of 0.39 before surgery. The patient was given 1 U of packed RBCs.

The thyroid function tests revealed the following values: thyroxine (T4), 464 nmol/L (36.2 µg/dL) (normal range, 64-144 nmol/L [5.0-11.2 µg/dL]); triiodothyronine (T3) uptake, 0.225 (normal range,0.245-0.39); free thyroxine index (FTI), 8.15 (normal range, 1.75-3.23); and thyrotropin (TSH), <0.01 mU/L (normal range, 0.3-4.0 mU/L. The β-hCG level fell to 82824 IU/L 2 days after surgery.

Pediatric Endocrinology Service was consulted 3 days after the surgery when the thyroid function test results became available. The patient then had no signs of hyperthyroidism, except for a heart rate of 120 and a wide pulse pressure of 128/50 mm Hg. The thyroid was not palpable. No nodules or Delphian node was palpated. She had no eye abnormalities or resting tremor of the tongue or the extremities. She reported no symptoms of hyperthyroidism before or after surgery, except occasional tachycardia (possibly due to the undiagnosed WPW). Bowel movements were normal. No antithyroid medication was given.

Four days after the surgery, β-hCG concentration was 21330 IU/L and thyroid function test values were T4, 246 nmol/L (19.2 µg/dL); T3 uptake, 0.27 FTI, 5.2; T3, 29 nmol/L (normal range, 1.2-2.9 nmol/L); and TSH, <0.01 mU/L. The patient was discharged home feeling well.

Repeated β-hCG concentration 5 days later was 957 IU/L, decreasing to 218 IU/L after 1 more week. One month after the surgery, the β-hCG level was 16 IU/L.

At 3 weeks after initial presentation, she remained clinically euthyroid. Her T4 level was 101 nmol/L (7.9 µg/dL); T3, 1.92 nmol/L; and TSH, 0.99 mU/L.




Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.


Some tools below are only available to our subscribers or users with an online account.

1 Citations

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections

The Rational Clinical Examination: Evidence-Based Clinical Diagnosis
Quick Reference

The Rational Clinical Examination: Evidence-Based Clinical Diagnosis
Quick Reference